(8) Information on how to file a claim for services received from non–participating providers because of an emergency within or outside of the service area shall be prominently disclosed.

(9) If there are restrictions on the choice of providers, a list of providers available to enrollees shall be included with the outline of coverage.

(10) The definition of grievance as contained in s. Ins 18.01 (4).

(11) The premium for the policy and riders, if any, in the following format:

MEDICARE SUPPLEMENT, MEDICARE SELECT AND MEDICARE COST PREMIUM INFORMATION

Annual Premium

$ (   )  BASIC MEDICARE SUPPLEMENT, MEDICARE SELECT, OR MEDICARE COST COVERAGE
 

OPTIONAL BENEFITS FOR MEDICARE SUPPLEMENT, MEDICARE SELECT, OR MEDICARE COST
POLICY

Each of these riders may be purchased separately.

(Note: Only optional coverages provided by rider shall be listed here.)

$ (    )  1. Medicare Part A deductible

  100% of Medicare Part A deductible

$ (    )   2. Additional home health care

  An aggregate of 365 visits per year including those covered by Medicare

$ (    )   3. Medicare Part B deductible

  100% of Medicare Part B deductible

$ (    )   4. Medicare Part B excess charges

  Difference between the Medicare eligible charge and the amount charged by the provider which shall be no greater than the actual charge or the limited charge allowed by Medicare, whichever is less

$ (    )   5.  Foreign travel rider

  After a deductible not greater than $250, covers at least 80% of expenses associated with emergency medical care received outside the U.S.A. beginning the first 60 days of a trip with a lifetime maximum of at least $50,000

$ (    )   TOTAL FOR BASIC POLICY AND SELECTED OPTIONAL BENEFITS

(Note: The soliciting agent shall enter the appropriate premium amounts and the total at the time this outline is given to the applicant. Medicare select policies and the Medicare Supplement 50% and 25% Cost-Sharing plans and Medicare Select 50% and 25% Cost-Sharing plans shall modify the outline to reflect the benefits that are contained in the policy and the optional or included riders.)

IN ADDITION TO THIS OUTLINE OF COVERAGE, [ISSUER] WILL SEND AN ANNUAL NOTICE TO YOU 30 DAYS PRIOR TO THE EFFECTIVE DATE OF MEDICARE CHANGES WITH WILL DESCRIBE THESE CHANGES AND THE CHANGES IN YOUR MEDICARE SUPPLEMENT COVERAGE.

(12) If premiums for each rating classification are not listed in the outline of coverage under subsection (11), then the issuer shall give a separate schedule of premiums for each rating classification with the outline of coverage.

(13) Include a summary of or reference to the coverage required by applicable statutes.

(14) The term “certificate” should be substituted for the word “policy” throughout the outline of coverage where appropriate.

Issuers shall select the appropriate outline of coverage specific to the type of plan being presented, Medicare supplement, Medicare supplement cost-sharing, Medicare cost, or Medicare select, from among the following Outlines of Coverage A through D, respectively.

OUTLINE OF COVERAGE - A

(COMPANY NAME)